THE BLOG

The Next Big Thing: Connecting Insured to Care

05/07/2014 03:01 pm ET | Updated Jul 07, 2014

With the Affordable Care Act's (ACA) first open enrollment period behind us, the next big task is connecting the newly insured to care. This will undoubtedly require significant effort and one we will struggle with in the coming years as population demographics change.

Part of the challenge is poor health literacy, a term the Institutes of Medicine describe as the degree to which individuals can obtain, process and understand the basic health information and services they need to make appropriate health decisions. Seventy-seven million Americans struggle with health literacy, which comes into play not only when following through on your doctor's recommendations, but in understanding how to use a health plan.

Racial and ethnic minority populations top those who face the most barriers, along with people with less education and the elderly. The challenges are compounded for the estimated 25 million limited-English proficient Americans. Imagine trying to not only figure out how to use your insurance, but also finding a provider that meets your health care needs or speaks your native tongue.

That's the situation Md Jalal Uddin, a Bangladeshi immigrant who speaks little English faced when he learned about the ACA through ethnic media. Uddin was relieved to get health insurance coverage for the first time in his life, but did not understand how an insurance card translated into a doctor's visit.

Uddin got help at the DREAM Project at the NYU Center for the Study of Asian American Health where MD Taher, a community health worker with hundreds of hours of experience, walked him through the online application and helped him select a health plan.

Community health workers (CHW) like Taher are members of the very communities they serve, and are often in the best position to provide assistance. They help explain the often befuddling terms that are part and parcel to private coverage -- copays, deductibles, premiums -- and assist individuals with finding a provider under a plan. Their years of experience and community connection make them trusted and reliable sources of information.

Most importantly, CHWs can be the bridge between getting coverage, using it and maintaining good health. Advisors at the DREAM project, for example, are experts in working with their local Bangladeshi community. When the ACA rolled in, Taher and his colleagues built on their years of experience and existing community buy-in to successfully navigate and enroll people in New York's Marketplace. And since they were already trained as CHWs, they can now provide those newly insured a seamless connection between coverage and care.

Serving as part of integrated health teams, these CHWs provide a workable model that ensures insurance coverage leads to better health outcomes. Studies have shown that CHWs can improve not only access to care, but help consumers manage chronic conditions, both situations that could benefit the medically underserved. Providing help after a patient leaves the doctor's office is just as important as the office visit itself, especially when managing chronic diseases such as diabetes and heart disease where patient lifestyle choices are of paramount importance.

Despite being around for decades, funding for CHWs remains a major challenge. Most community-based organizations doing this work subsist on federal and state funding or private foundation dollars to support these efforts. In today's fiscal climate, this is not sustainable. One solution is to fully integrate community workers into health teams and make them reimbursable by third-party payers, both public and private. Creating a long-term sustainable funding source is needed to have real integration of patient navigators and community workers and fully realize their value.

The Centers for Medicare & Medicaid Services (CMS) recently issued a final rule that offers one such opportunity. States can now use Medicaid dollars to reimburse for preventive services recommended by both physicians and other licensed practitioners. The new rule opens the door to having Medicaid cover preventive services recommended by a larger array of providers, including community health workers, for services such as care coordination and covered health education. If states widely adopt this policy, we could increase access for underserved communities who rely on community health workers and other non-licensed providers for care.

With millions more newly insured, CHWs are playing an increasing role on the front-lines, both in increasing access to coverage and serving as health teams in delivery system reforms. To truly maximize their impact, however, funding mechanisms must catch up to patient need. As the health policy world moves beyond just enrollment, CHWs -- and sustainable and integrated funding sources for them -- should be part of the conversation at the federal, state and local levels.